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Enrollment Intake Form

Let’s get started.

Your Intake Form

Welcome! I'm looking forward to working with you. Take your time with this and be as open and detailed as you can. Here are a few pointers: Try not to worry about what I will think. Don’t judge what comes up for you or edit your thoughts in any way. Nothing is too big or too small to mention - everything applies. It's all part of your life. Some of these questions may not trigger any memories, and that’s fine. Simply note that nothing stands out in that section. This is important work. Be as honest with yourself as possible to help the breakthrough process. It is not necessary to write long stories, feel free to share time lines or outline “bullet point” style. As always, everything you share is 100% confidential.

Coaching Contract*
As we begin, it is useful to be sure we are aligned in our understanding of the nature of our coaching relationship. Please check below to indicate you agree:
- I understand that this is a coaching relationship that is distinct from therapy and consulting. As your coach, Renee will invite and support your exploration of options, resources, strategies, actions, and choices. I acknowledge that, in undertaking one or more sessions of physical, emotional, spiritual and mental coaching with Renee Jayne, I am responsible for the consequences. It is my job to decide what is useful from them for my personal development.
Coaching Contract - 02*
- I acknowledge that, a minimum of 24 hours’ advance notice is required to cancel or reschedule. Rescheduling occurs on the basis of available space. Cancellations or reschedules within 24 hours, or failure to show to an appointment, will result in a loss of that session. (Renee gives each client one “goof” before the loss of a session would occur for a missed appointment)
Coaching Contract - 03*
- I understand the importance and value to being on time and fully present for my sessions. If on the phone or Skype or Zoom, I agree to be in a quiet, private place for the session. I will refrain from driving, eating, or multitasking during our time together. (If you find it challenging to find physical space or space in your schedule for the coaching sessions, please bring your schedule to our first session so that we may explore the underlying challenges and support you with putting in place a strategy that works for you).
Coaching Contract - 03*
- I will speak the truth to you as I see it. I understand that I can expect Renee to do the same. I understand that this coaching relationship is playground to explore new ways of relating to someone else and myself.
Coaching Contract - 04*
- In this capacity, I understand that Renee, as a holistic health practitioner is not holding herself out to be a Medical Provider (including doctor/physician, nurse, physician’s assistant or any other health professional), Mental Health Provider (including psychiatrist, psychologist, therapist, counselor, or social worker), registered dietician or member of the clergy. Rather, I serve you as a trainer, educator, coach, mentor and holistic practitioner and guide who provides health, life and nutrition education and learning opportunities to all individuals in need of heath advice.
Name*
First Last
Phone*
Email*
Skype and Social
(optional)
FILE SHARE
File Upload
Feel free to share your most recent blood work or anything pertinent to the work we are doing together.
Drop files here or
GOALS
Please describe your health goals and aspirations.*
Why these are so important to your right now? (Describe)*
YOUR HEALTH STATS
Birthdate*
Gender
Height*
Current Weight
Birthweight (if known)
Blood Type
Family. Who do you live with?*
Do you have children (Animal children included!)?
Occupation*
Explain your current exercise and recreation habits*
HEALTH CONCERNS
What are you main health concerns? Please describe in detail.*
How have you dealt with these concerns in the past (doctors, self care, therapists, coaches, courses)*
What other doctors or practitioners are your currently working with. (List name, speciality and phone)*
List ALL medicines and supplements you are currently taking.*
Have any other family members had similar problems? If yes, please describe.
Please check any of the following conditions that apply to your history.*
- Cancer
- Heart Disease
- Hepatitis
- Venereal Disease
- Autoimmune
- Gluten Intolerance
- Diabetes
- High Blood Pressure
- Chronic Pain
- Hormonal Imbalance
- High Cholesterol
- Kidney Disease
- Migraines
- Thyroid Disease
- Urinary Track Infections
- Depression
- Asthma
- Allergies
- Anemia
- Chronic Yeast or Candida
- Heartburn or Indigestion
- Swollen extremities
- Arthritis
- Chronic skin problems
- Physical pain
- Chronic sinus problems
- Addiction (drugs, alcohol, food, sugar, caffeine, prescription drugs)
- Other (explain below)
Below, briefly describe your symptoms, chosen treatment(s), and dates.*
PREVENTATIVE HEALTH QUESTIONS
How do you handle stress?*
Have you been exposed to, or are you sensitive to chemicals? Do you take consistent artificial sweeteners, over the counter drugs, chemical residues, medicines, food additives?*
Do you have or have you had trauma or abuse - physical or emotional. If so, explain.*
Do you have any "toxic" relationships in your life? If so, with who and give some examples how this may be impacting you in your day to day life.
Have you had periods of eating junk food, binge eating, dieting, drinking or drug use? [List any known pattern, addictive habits or obsessive diets that you have been on for a significant amount of time.]
Have you used or abused alcohol, drugs, meds, tobacco, caffeine, relationships, social media,*
Describe your sleep patterns. Can you get to sleep easily? Can you stay asleep? How many hours do you average per night?*
How are your moods in general? Do you experience more than you would like of anxiety? Depression? Anger?*
Describe your current diet. Be as descriptive as possible (breakfast, lunch, dinner, snacks, cravings, favorite brands, restaurants, beverages, chocolates, etc)*
Describe how are your moods and energy level affected by eating these foods (nourished or numbing)?*
Do you have any known food allergies or sensitivities?**
How many times a day do you typically have a bowel movement?*
Do you experience gas or bloating or constipation or diarrhea? (Describe)*
Answer this question: The most important thing I should change about my diet to improve my health is*
Please describe any other information you think would be useful in helping to address your health concern(s)*
Your responses will be sent directly to Renee so she can review before your session. A copy will also be sent to your email. Double check your spam folder if you don't see it. If you have any questions, please email support@reneeheigel.com